About the service: Hopes Green is a residential care home that was providing personal care and accommodation for up to 50 older people, some of whom had physical frailty or were living with dementia. On the days of the inspection, there were 49 people living at the home.

People’s experience of using this service:

The home was overall unclean and poorly maintained. We identified concerns with infection prevention and control measures in place.

Documentation was not always completed to evidence that routine daily tasks had been completed in areas such as care delivery, health and safety and cleanliness.

Staffing levels were not appropriate for people’s assessed needs. Communal areas were left unstaffed for significant periods of time which meant that people’s care and safety needs were not always met.

The provider has a quality assurance system in place and regular checks of the service provided were carried which identified areas of concern, however the necessary improvements had not been made.

People received their medicines as prescribed. We have made a recommendation about the management of topical medicines and creams.

People were supported to engage in meaningful activities. We have made a recommendation about dedicated activities staff to ensure that more people can access activities or dedicated one to one time on a regular basis.

Risks associated with people’s health and care were assessed and staff knew how to keep people safe.

Staff were caring, dedicated and treated people with dignity and respect. People told us they liked living at Hopes Green.

Staff had received training to enable them to provide effective care. Supervisions had been inconsistent but this was improving.

People's capacity to make day-to-day decisions had been considered and assessed and the provider was working within the requirements of the Mental Capacity Act 2005 and Deprivation of Liberty Safeguards.

Complaints were investigated and responded to.

We received positive feedback about the open and transparent culture in the home.

Rating at last inspection: At the last inspection this service was rated Good (Report published May 2016).

Why we inspected: This was a planned inspection based on the rating at the last inspection.

Follow up: Due to the regulatory breaches identified on the inspection, we formally wrote to the provider to request an action plan to address our concerns. We will continue to monitor progress made against the provider's action plan and any regulatory action as an outcome of this full inspection report.

For more details, please see the full report which is on the CQC website at www.cqc.org.uk

The inspection took place on the 4 and 9 May 2016 and was announced.

Hopes Green is registered to provide accommodation and care for up to 50 people some of whom may be living with dementia. There were 49 people living at the service at the time of our inspection. The home does not provide nursing care.

A manager was in post and was going through the process to become a registered manager with the Care Quality Commission. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Like registered providers, they are ‘registered persons’. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run. The manager was supported by a deputy manager to ensure the daily management of the service.

People told us the service was a safe place to live. The registered provider’s recruitment procedures ensured that only suitable staff were employed. People were supported by staff that had the skills and experience needed to provide effective care and there were enough staff to help keep people safe and meet their needs. Staff had a good understanding and knowledge of safeguarding procedures and were clear about the actions they would take to protect the people they supported. Risks to people’s health and wellbeing were appropriately assessed, managed and reviewed. Medication was managed and administered safely and people received their medicines as prescribed.

Assessments of people’s capacity were carried out in line with the Mental Capacity Act 2005 (MCA). The manager and staff understood and complied with the requirements of the MCA and the associated Deprivation of Liberty Safeguards (DoLS).

Staff knew people well and understood how to meet their care and support needs. People and, where appropriate, their families were fully involved in the planning and review of their care; care plans were person centred and were regularly reviewed. Staff promoted people’s independence and encouraged people to do as much as possible for themselves.

Staff were kind and caring and treated people with respect and dignity. People and their relatives told us they were happy with the care and support they received. People’s nutritional needs were met and people were supported to maintain a healthy and balanced diet. People were supported to access health and social care professionals and services when needed.

People living and working in the service had the opportunity to say how they felt about the service provided. Their views were listened to and actions were taken in response. There was an effective system in place to respond to complaints and concerns.

There were a number of effective systems in place to regularly assess and monitor the quality of the service. The manager was able to demonstrate how they measured and analysed the care and support provided to people to ensure the service was operating safely and was continually improving to meet people’s needs.

We had received some information of concern and therefore decided to carry out a responsive review of the service. During our inspection we spoke with 13 people who used the service and five visiting relatives and friends. We also spoke with the manager and five staff.

Hopes Green provided a service for people with personal care and dementia related needs. We looked at the care records for six people who used the service. We also looked at how people were involved and consented to their care, staffing and quality assurance checks.

We considered our inspection findings to answer questions we always ask; Is the service safe? Is the service effective? Is the service caring? Is the service responsive? Is the service well-led?

This is a summary of what we found;

Is the service safe?

The service had ensured that staff were provided with the knowledge and skills to keep people safe and protect them from harm.

All staff had received training in the Safeguarding of Vulnerable Adults from Abuse (SOVA), the Mental Capacity Act (MCA) 2005 and Deprivation of Liberty Safeguards (DoLS). Staff we spoke with told us that they were aware of the action they would take if they suspected abuse was or had taken place.

We found that the service had suitable arrangements in place to gain people’s consent and assess their mental capacity to make decisions before acting on their behalf. No DoLS authorisations were in place for anyone at the service, although applications had been made after assessments had been completed.

The policy, procedures and quality monitoring of the service included health and safety, dependency scores and reviews of care planning and delivery. People were provided with care and support that ensured their welfare and safety.

Is the service effective?

People's assessments showed that their care, support and treatment was planned and delivered in a way that ensured that their needs were being met. People were fully involved, where possible, in choices and decisions about their lives. This made their care more effective as it enhanced their wellbeing and independence. One person said, "Yes I am fully involved in all things to do with me. I do things my own way and that is what I like."

Is the service caring?

We saw good interaction between staff and people who used the service. Staff spoke to people respectfully; they were considerate, courteous and kind. People told us that the staff were very caring. One person said, "Oh yes, they [staff] are lovely people, never grumpy in the mornings like me and always come in with a smile."

Staff had a good knowledge of people’s likes and dislikes. People told us that the staff treated them respectfully. People’s preferences and diverse needs had been recorded in their care files and care and support had been provided in accordance with their wishes. This showed that people were cared for by staff who were respectful and caring.

Is the service responsive?

Regular checks on the dependency levels of people who used the service were undertaken. There were sufficient staff on duty to respond to people’s needs appropriately.

The service offered a range of activities for people to enjoy. These had been developed from listening to the views of people who used the service and their relatives. One person said, "I think there is enough to do, if you want to do things." Another person said, "It is up to us to say what we want to do and to help organise the things we want to do."

We saw from the records viewed that the service worked well with other agencies. A range of health and social professionals from the community were involved in people’s care. This showed that people received their care in a joined up way.

Is the service well-led?

A comprehensive quality monitoring process and improvement plan was in place. Regular care reviews and discussions about people’s quality of life at Hopes Green were discussed with them and their families. This ensured that people’s changing needs and preferences were always taken into account.

Staffing levels were reviewed in order to ensure there were always sufficient staff to meet people’s needs.

The service was well-led as it was continually improving in its care provision and in the environment to make Hopes Green a good place to live and work.

In this report the name of a registered manager appears who was not in post at this location at the time of the inspection. Their name appears because they were still a registered manager on our register at the time.

Each person was noted to have a support plan in place detailing their specific care needs and how they were to be supported by staff. Records showed that people who use the service were supported to maintain their healthcare needs. We saw that staff arranged for people to be seen by their doctor when they became unwell or their medical or mental health condition required a review. People told us they liked living at Hopes Green and found the staff to be kind and caring. People we spoke with said they were happy with the way the service managed their medicines.

The atmosphere within the service was calm and relaxed and staff interactions with people who lived there were noted to be positive. Staff were able to demonstrate a good understanding of people’s care and support needs.

Records showed that the provider had an effective recruitment and selection process in place and this involved all relevant checks being carried out prior to the member of staff commencing employment at Hopes Green.

Although the service had received a small number of complaints and safeguarding concerns, appropriate systems were in place to deal with these. Records showed that these had been addressed by the Local Authority and provider.

We directly observed care within the service so as to help us determine what it was like for people living at Hopes Green. We found that staff interactions with people who live at the service were positive. Staff were seen to have a good awareness and understanding of people's individual needs. People spoken with told us that they liked living at Hopes Green and found the care and support to meet their needs.

We found at this visit that appropriate improvements in relation to the service's quality assurance system had been made to ensure positive outcomes for people who use the service. However we found that further improvements were required to ensure that people are protected against the risks associated with medicines management and that their personal records are accurate.

Where people were unable to provide a verbal response or tell us verbally their experiences, for example as a result of their limited verbal communication or poor cognitive ability, we noted their non verbal cues and these indicated that the majority of people in the home were relaxed and comfortable and found their experience at the home to be positive.

Three people spoken with told us that they were happy living at Hopes Green and that they found the care and support provided by staff to be good. People told us that they were treated well by care staff and that their privacy and dignity were respected. They also confirmed that they had no concerns about the staffing numbers at the home.

We did not speak to people using the service about the outcome we looked at during this visit.

On this occasion we did not speak with anyone who uses the service about the way the home manages their medicines.

Where people were unable to provide a verbal response or tell us verbally their experiences, we noted their non verbal cues and these indicated that some people were relaxed and comfortable and found their experience at the home to be positive. However, our observations also showed that some people found their experience to be of poor quality.

Five people spoken with told us that the staff were lovely and caring however they felt that there were insufficient staff available on occasions to meet their care needs. People told us that few staff came in and talked to them on an individual basis. People told us that on some occasions when personal care support was being provided by a specific member of staff they could be called away. People told us that staff had good intentions and would state that they would come back later but sometimes this did not always happen and when staff did return it was not always the original member of staff. Two people told us that they found it difficult to understand and/or communicate effectively with staff whose first language was not English. One person told us “I have been perfectly happy here, the home has changed dramatically and I have to admit I have shed a few tears recently. The new owners are trying to make changes too quickly.”

People told us that there were not always enough staff about and that they could be left unsupervised and without staff support for long periods of time. People told us that although agency staff were deployed at the home, they did not always feel that agency staff knew their specific care needs. Comments included “The care and support provided is not as good as it used to be”, “You have to wait on occasions for care to be provided, they do it when they can” and “I don’t like it here now, staff are so busy.” When we asked another person who uses the service as to what they thought of the staffing levels at Hopes Green, their reply was “We haven’t got any we are regularly short of staff.”

Four relatives spoken with told us that they found care staff to be “lovely and caring” but that they did not feel there were sufficient members of staff available to meet people's care needs. One comment included “Staff are disgustingly overstretched and this is impacting on care provided such as no regular baths and no stimulation (activities) for people during the day.” Another comment included “Our concerns are that our relative and others living at the home are only receiving a ‘basic’ level of care.”

During our visit we were able to hold a conversation with four people. Others were able to make comments about specific issues, such as the quality of the meals, whether or not they liked their room, if they liked staff, if they liked living at Hopes Green; however most of the information about people’s experiences was gathered through our observations.

In general people with whom we spoke, told us, that they were happy living at Hopes Green and they found the staff to be nice and caring. Comments included “the staff are lovely” and “I like it here, the care and support is good.” Another person, with whom we spoke, told us, “I’m so lucky to have my cat here; I wouldn’t know what to do if I didn’t have him.”

People told us that they felt safe and that, if they had any concerns or worries, they would discuss them with their relative or a member of staff. However one person, with whom we spoke, told us, that they were unsure who to talk with if they had any concerns and that they did not always feel listened to by staff.

We also received some negative comments. One person, with whom we spoke, told us, that they found not all staff was nice, caring and/or patient. They told us that some staff could be slow to respond to the call alarm bell and that staff did not always talk to them when undertaking personal care tasks. They told us “I feel so lonely at times, I just sit here staring at the television. It’s a long time, a long time”, “Staff see you as a nuisance, they say I’ll come back in a minute, but they never do” and “I’m so alone, I can go for hours on my own before someone comes in.”